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Stuijt PJC, Heringa M, van Dijk L, Faber A, Burgers JS, Feenstra TL, Taxis K, Denig P. Effects of a multicomponent communication training to involve older people in decisions to DEPRESCRIBE cardiometabolic medication in primary care (CO-DEPRESCRIBE): protocol for a cluster randomized controlled trial with embedded process and economic evaluation. BMC PRIMARY CARE 2024; 25:210. [PMID: 38862899 PMCID: PMC11165805 DOI: 10.1186/s12875-024-02465-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 06/03/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Deprescribing of medication for cardiovascular risk factors and diabetes has been incorporated in clinical guidelines but proves to be difficult to implement in primary care. Training of healthcare providers is needed to enhance deprescribing in eligible patients. This study will examine the effects of a blended training program aimed at initiating and conducting constructive deprescribing consultations with patients. METHODS A cluster-randomized trial will be conducted in which local pharmacy-general practice teams in the Netherlands will be randomized to conducting clinical medication reviews with patients as usual (control) or after receiving the CO-DEPRESCRIBE training program (intervention). People of 75 years and older using specific cardiometabolic medication (diabetes drugs, antihypertensives, statins) and eligible for a medication review will be included. The CO-DEPRESCRIBE intervention is based on previous work and applies models for patient-centered communication and shared decision making. It consists of 5 training modules with supportive tools. The primary outcome is the percentage of patients with at least 1 cardiometabolic medication deintensified. Secondary outcomes include patient involvement in decision making, healthcare provider communication skills, health/medication-related outcomes, attitudes towards deprescribing, medication regimen complexity and health-related quality of life. Additional safety and cost parameters will be collected. It is estimated that 167 patients per study arm are needed in the final intention-to-treat analysis using a mixed effects model. Taking loss to follow-up into account, 40 teams are asked to recruit 10 patients each. A baseline and 6-months follow-up assessment, a process evaluation, and a cost-effectiveness analysis will be conducted. DISCUSSION The hypothesis is that the training program will lead to more proactive and patient-centered deprescribing of cardiometabolic medication. By a comprehensive evaluation, an increase in knowledge needed for sustainable implementation of deprescribing in primary care is expected. TRIAL REGISTRATION The study is registered at ClinicalTrials.gov (identifier: NCT05507177).
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Affiliation(s)
- Peter J C Stuijt
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, PO-Box 30001, HPC AP50, UMCG, Groningen, 9700RB, The Netherlands
| | - Mette Heringa
- SIR Institute for Pharmacy Practice and Policy, Leiden, The Netherlands
| | - Liset van Dijk
- Nivel, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
- Unit of PharmacoTherapy, - Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Adrianne Faber
- SIR Institute for Pharmacy Practice and Policy, Leiden, The Netherlands
| | - Jako S Burgers
- Department of Family Medicine, School CAPHRI, Maastricht University, Maastricht, The Netherlands
- Dutch College of General Practitioners, Utrecht, The Netherlands
| | - Talitha L Feenstra
- Unit of PharmacoTherapy, - Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
- Dutch National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Katja Taxis
- Unit of PharmacoTherapy, - Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, PO-Box 30001, HPC AP50, UMCG, Groningen, 9700RB, The Netherlands.
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Pilla SJ, Maruthur NM. Crossing the deintensification chasm for older adults with diabetes. J Am Geriatr Soc 2024. [PMID: 38738883 DOI: 10.1111/jgs.18944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 03/25/2024] [Accepted: 04/09/2024] [Indexed: 05/14/2024]
Abstract
This editorial comments on the article by Haider et al.
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Affiliation(s)
- Scott J Pilla
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nisa M Maruthur
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Pilla SJ, Jalalzai R, Tang O, Schoenborn NL, Boyd CM, Bancks MP, Mathioudakis NN, Maruthur NM. A National Survey of Physicians' Views on the Importance and Implementation of Deintensifying Diabetes Medications. J Gen Intern Med 2024; 39:992-1001. [PMID: 37940754 DOI: 10.1007/s11606-023-08506-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/20/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Guidelines recommend deintensifying hypoglycemia-causing medications for older adults with diabetes whose hemoglobin A1c is below their individualized target, but this rarely occurs in practice. OBJECTIVE To understand physicians' decision-making around deintensifying diabetes treatment. DESIGN National physician survey. PARTICIPANTS US physicians in general medicine, geriatrics, or endocrinology providing outpatient diabetes care. MAIN MEASURES Physicians rated the importance of deintensifying diabetes medications for older adults with type 2 diabetes, and of switching medication classes, on 5-point Likert scales. They reported the frequency of these actions for their patients, and listed important barriers and facilitators. We evaluated the independent association between physicians' professional and practice characteristics and the importance of deintensifying and switching diabetes medications using multivariable ordered logistic regression models. KEY RESULTS There were 445 eligible respondents (response rate 37.5%). The majority of physicians viewed deintensifying (80%) and switching (92%) diabetes medications as important or very important to the care of older adults. Despite this, one-third of physicians reported deintensifying diabetes medications rarely or never. While most physicians recognized multiple reasons to deintensify, two-thirds of physicians reported barriers of short-term hyperglycemia and patient reluctance to change medications or allow higher glucose levels. In multivariable models, geriatricians rated deintensification as more important compared to other specialties (p=0.027), and endocrinologists rated switching as more important compared to other specialties (p<0.006). Physicians with fewer years in practice rated higher importance of deintensification (p<0.001) and switching (p=0.003). CONCLUSIONS While most US physicians viewed deintensifying and switching diabetes medications as important for the care of older adults, they deintensified infrequently. Physicians had ambivalence about the relative benefits and harms of deintensification and viewed it as a potential source of conflict with their patients. These factors likely contribute to clinical inertia, and studies focused on improving shared decision-making around deintensifying diabetes medications are needed.
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Affiliation(s)
- Scott J Pilla
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Rabia Jalalzai
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Olive Tang
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nancy L Schoenborn
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cynthia M Boyd
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael P Bancks
- Department of Epidemiology & Prevention, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Nestoras N Mathioudakis
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nisa M Maruthur
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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Alhurishi SA, AlQahtani MF. Are Saudi Arabian Patients Willing to Be Deprescribed Their Medications? An Exploratory Study. Patient Prefer Adherence 2024; 18:779-786. [PMID: 38562243 PMCID: PMC10982065 DOI: 10.2147/ppa.s446873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 03/05/2024] [Indexed: 04/04/2024] Open
Abstract
Purpose Deprescribing is a complex process that requires active patient involvement, so the patient's attitude to deprescribing is crucial to its success. This study aimed to assess predictors of Saudi Arabian patients' willingness to deprescribe. Patients and Methods In this cross-sectional study, adult patients from two hospitals in Riyadh completed a self-administered questionnaire gathering data on demographic information and the Arabic revised Patients' Attitudes Towards Deprescribing (rPATD) questions. Descriptive analysis and binary logistic regression were used to analyze the data. Results A total of 242 patients were included (mean age 59.8 (SD 11.05) years, range 25-87 years; 40% 60-69 years; 54.1% female). The majority (90%) of participants were willing to have medications deprescribed. Willingness to deprescribe was significantly associated with the rPATD involvement factor (OR=1.866, 95% CI 1.177-2.958, p=0.008) and the patient's perception of their health status (OR=2.08, CI=1.058-4.119, p=0.034). Conclusion The majority of patients were willing to have one or more medications deprescribed if recommended by their doctors. Patient perceptions about their own health and their involvement in deprescribing were important predictive factors that could shape counseling and education strategies to encourage deprescribing.
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Affiliation(s)
- Sultana A Alhurishi
- Community Health Sciences Department, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
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Pajewski NM, Cohen JB. ATEMPTing to navigate between "lower is better" and "less is more". THE LANCET. HEALTHY LONGEVITY 2024; 5:e164-e165. [PMID: 38342122 DOI: 10.1016/s2666-7568(24)00024-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 01/30/2024] [Indexed: 02/13/2024] Open
Affiliation(s)
- Nicholas M Pajewski
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, PA, USA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, PA, USA
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Mellot M, Jawal L, Morel T, Fournier JP, Tubach F, Cadwallader JS, Christiaens A, Zerah L. Barriers and Enablers for Deprescribing Glucose-Lowering Treatment in Older Adults: A Systematic Review. J Am Med Dir Assoc 2024; 25:439-447.e18. [PMID: 38237904 DOI: 10.1016/j.jamda.2023.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/21/2023] [Accepted: 11/28/2023] [Indexed: 01/27/2024]
Abstract
OBJECTIVES Overtreatment with glucose-lowering treatment (GLT) is frequent and a source of high morbidity and mortality in older adults with type 2 diabetes mellitus (T2DM). This study aimed to identify and synthesize barriers and enablers for deprescribing GLT in older adults (≥65 years) with T2DM. DESIGN Systematic review of qualitative and mixed-methods studies. SETTING AND PARTICIPANTS Older adults with T2DM, any participants [patients, health care providers (HCPs), caregivers], any settings. METHODS Two researchers (and a referred third researcher at all stages) independently screened original articles reporting qualitative and mixed-methods studies exploring barriers and enablers for deprescribing GLT in older adults published during 2010-2023, identified from MEDLINE, Embase, CINAHL, and gray literature. Quality of the included studies was assessed with the Mixed-Methods Appraisal Tool. Verbatim statements on barriers and enablers were extracted, and determinants of behaviors were identified with the Theoretical Domains Framework (TDF) version 2, and related intervention functions (targets for future interventions) were proposed according to the Behavior Change Wheel (BCW). RESULTS We identified only 4 studies from 2 countries (United States and the Netherlands), all recently published (2019-2023), that primarily reported barriers to GLT deprescribing from interviews or focus groups of patients or HCPs practicing outpatient medicine. Knowledge, fear, poor communication, inertia, and trust with HCPs were the main determinants of behaviors that influenced deprescribing, and education, training, persuasion and environmental restructuring were the main intervention functions for proposing future interventions. Studies did not cover financial aspects, physician characteristics, or caregiver and family viewpoints. CONCLUSIONS AND IMPLICATIONS The use of a behavioral theory and a validated implementation framework provided a comprehensive approach to identifying barriers and enablers for deprescribing GLT in older adults (≥65 years) with T2DM. The behavioral determinants identified may be useful in tailoring interventions to improve the implementation of GLT deprescribing in older adults in ambulatory settings.
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Affiliation(s)
- Marion Mellot
- Département de gériatrie, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Pitié Salpêtrière, Paris, France
| | - Lina Jawal
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), Paris, France
| | - Thomas Morel
- Département de Médecine Générale, Faculté de Médecine, Nantes Université, Nantes, France
| | - Jean-Pascal Fournier
- Département de Médecine Générale, Faculté de Médecine, Nantes Université, Nantes, France; Université Tours-Nantes, INSERM, UMR U1246 SPHERE "Methods in Patient-Centered Outcomes and Health Research", Tours, France
| | - Florence Tubach
- Département de Santé Publique, Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP), Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Pitié Salpêtrière, Centre de Pharmacoépidémiologie (Cephepi), Paris, France
| | - Jean-Sébastien Cadwallader
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), Paris, France; Département de Médecine Générale, Sorbonne Université, Paris, France
| | - Antoine Christiaens
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), Paris, France; Fonds de la Recherche Scientifique (FNRS), Brussels, Belgium; Clinical Pharmacy Research Group, Louvain Drug Research Institute (LDRI), Université catholique de Louvain, Brussels, Belgium
| | - Lorène Zerah
- Département de gériatrie, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Pitié Salpêtrière, Paris, France; Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), Paris, France.
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Baas G, Crutzen S, Smits S, Denig P, Taxis K, Heringa M. Process evaluation of a pharmacist-led intervention aimed at deprescribing and appropriate use of cardiometabolic medication among adult people with type 2 diabetes. Basic Clin Pharmacol Toxicol 2024; 134:83-96. [PMID: 37563775 DOI: 10.1111/bcpt.13931] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 07/13/2023] [Accepted: 08/01/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND A quasi-experimental study investigated a pharmacist-led intervention aimed at deprescribing and medication management among adult patients with type 2 diabetes at risk of hypoglycaemia. OBJECTIVE This study aimed to evaluate the process of implementing the intervention consisting of a tailored clinical medication review (CMR) supported by a training and a toolbox. METHODS Mixed-methods study based on the Grant framework, including the domains "recruitment," "delivery of intervention" and "response" of pharmacists and patients. Data collected were administrative logs, semi-structured observations of patient consultations (n = 8), interviews with pharmacists (n = 16) and patient-reported experience measure (PREM) questionnaires (n = 66). RESULTS Tailored CMRs were conducted largely as intended for 90 patients from 14 pharmacies. Although patient selection based on a medication-derived hypoglycaemia risk score was considered useful, pharmacists experienced barriers to proposing deprescribing in patients with recent medication changes, without current hypoglycaemic events, or treated by medical specialists. The training and toolbox were evaluated positively by the pharmacists. Overall, patients were satisfied with the CMR. CONCLUSION Pharmacists and patients valued the CMR focusing on deprescribing and medication management. To optimize implementation and effectiveness of the intervention, improvements can be made to the patient selection, pharmacist training and the collaboration between healthcare professionals.
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Affiliation(s)
- Gert Baas
- SIR Institute for Pharmacy Practice and Policy, Leiden, The Netherlands
- Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Stijn Crutzen
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Sanne Smits
- Unit of PharmacoTherapy, -Epidemiology, and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Katja Taxis
- Unit of PharmacoTherapy, -Epidemiology, and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Mette Heringa
- SIR Institute for Pharmacy Practice and Policy, Leiden, The Netherlands
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Pilla SJ, Meza KA, Beach MC, Long JA, Gordon HS, Bates JT, Washington DL, Bokhour BG, Tuepker A, Saha S, Maruthur NM. Assessment and prevention of hypoglycaemia in primary care among U.S. Veterans: a mixed methods study. LANCET REGIONAL HEALTH. AMERICAS 2023; 28:100641. [PMID: 38076413 PMCID: PMC10701452 DOI: 10.1016/j.lana.2023.100641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 02/12/2024]
Abstract
Background Hypoglycaemia from diabetes treatment causes morbidity and lower quality of life, and prevention should be routinely addressed in clinical visits. Methods This mixed methods study evaluated how primary care providers (PCPs) assess for and prevent hypoglycaemia by analyzing audio-recorded visits from five Veterans Affairs medical centres in the US. Two investigators independently coded visit dialogue to classify discussions of hypoglycaemia history, anticipatory guidance, and adjustments to hypoglycaemia-causing medications according to diabetes guidelines. Findings There were 242 patients (one PCP visit per patient) and 49 PCPs. Two thirds of patients were treated with insulin and 40% with sulfonylureas. Hypoglycaemia history was discussed in 78/242 visits (32%). PCPs provided hypoglycaemia anticipatory guidance in 50 visits (21%) that focused on holding diabetes medications while fasting and carrying glucose tabs; avoiding driving and glucagon were not discussed. Hypoglycaemia-causing medications were de-intensified or adjusted more often (p < 0.001) when the patient reported a history of hypoglycaemia (15/51 visits, 29%) than when the patient reported no hypoglycaemia or it was not discussed (6/191 visits, 3%). Haemoglobin A1c (HbA1c) was not associated with diabetes medication adjustment, and only 5/12 patients (42%) who reported hypoglycaemia with HbA1c <7.0% had medications de-intensified or adjusted. Interpretation PCPs discussed hypoglycaemia in one-third of visits for at-risk patients and provided limited hypoglycaemia anticipatory guidance. De-intensifying or adjusting hypoglycaemia-causing medications did not occur routinely after reported hypoglycaemia with HbA1c <7.0%. Routine hypoglycaemia assessment and provision of diabetes self-management education are needed to achieve guideline-concordant hypoglycaemia prevention. Funding U.S. Department of Veterans Affairs and National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).
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Affiliation(s)
- Scott J. Pilla
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
| | - Kayla A. Meza
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Mary Catherine Beach
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health, Behavior & Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Judith A. Long
- Corporal Michael J. Cresenz VA Medical Center, Philadelphia, PA, USA
- Division of General Internal Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Howard S. Gordon
- Jesse Brown VA Medical Center, Chicago, IL, USA
- Division of Academic Internal Medicine and Geriatrics, Department of Medicine, University of Illinois Chicago College of Medicine, Chicago, IL, USA
| | - Jeffrey T. Bates
- Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| | - Donna L. Washington
- VA Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, Department of Medicine, Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Barbara G. Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Health Care System, Bedford, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Anais Tuepker
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Somnath Saha
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Nisa M. Maruthur
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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Koehn DA, Dungan KM, Wallia A, Lucas DO, Lash RW, Becker MN, Dardick LD, Boord JB. Reducing hypoglycemia from overtreatment of type 2 diabetes in older adults: The HypoPrevent study. J Am Geriatr Soc 2023; 71:3701-3710. [PMID: 37736005 DOI: 10.1111/jgs.18566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 06/22/2023] [Accepted: 06/25/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Hypoglycemia from overtreatment is a serious but underrecognized complication among older adults with type 2 diabetes. However, diabetes treatment is seldom deintensified. We assessed the effectiveness of a Clinical Decision Support (CDS) tool and shared decision-making (SDM) in decreasing the number of patients at risk for hypoglycemia and reducing the impact of non-severe hypoglycemic events. METHODS HypoPrevent was a pre-post, single arm study at a five-site primary care practice. We identified at-risk patients (≥65 years-old, with type 2 diabetes, treated with insulin or sulfonylureas, and HbA1c < 7.0%). During three clinic visits over 6 months, clinicians used the CDS tool and SDM to assess hypoglycemic risk, set individualized HbA1c goals, and adjust use of hypoglycemic agents. We assessed the number of patients setting individualized HbA1c goals or modifying medication use, changes in the population at risk for hypoglycemia, and changes in impact of non-severe hypoglycemic events using a validated patient-reported outcome tool (TRIM-HYPO). RESULTS We enrolled 94 patients (mean age-74; mean HbA1c (±SD)-6.36% ± 0.43), of whom 94% set an individualized HbA1c goal at either the baseline or first follow-up visit. Ninety patients completed the study. Insulin or sulfonylurea use was decreased or eliminated in 20%. An HbA1c level before and after goal setting was obtained in 53% (N = 50). Among these patients, the mean HbA1c increased 0.53% (p < 0.0001) and the number of patients at-risk decreased by 46% (p < 0.0001). Statistically significant reductions in the impact of hypoglycemia during daily activities occurred in both the total score and each functional domain of TRIM-HYPO. CONCLUSIONS In a population of older patients at risk for hypoglycemia, the use of a CDS tool and SDM reduced the population at risk and decreased the use of insulin and sulfonylureas. Using a patient-reported outcome tool, we demonstrated significant reductions in the impact of hypoglycemia on daily life.
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Affiliation(s)
| | - Kathleen Marie Dungan
- Division of Endocrinology, Diabetes & Metabolism, The Ohio State University, Columbus, Ohio, USA
| | - Amisha Wallia
- Division of Endocrinology, Metabolism & Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | | | | | | | - Jeffrey B Boord
- Department of Administration and Parkview Physicians Group Endocrinology Section, Parkview Health System, Fort Wayne, Indiana, USA
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Berry SD, Hecker EJ, McConnell ES, Xue TM, Tsai T, Zullo AR, Colón-Emeric C. Nursing Home PRevention of Injury in DEmentia (NH PRIDE): A pilot study of a remote injury prevention service for NH residents. J Am Geriatr Soc 2023; 71:3267-3277. [PMID: 37596877 PMCID: PMC10592133 DOI: 10.1111/jgs.18564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 07/20/2023] [Accepted: 08/02/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Medication optimization, including prescription of osteoporosis medications and deprescribing medications associated with falls, may reduce injurious falls. Our objective was to describe a remote, injury prevention service (NH PRIDE) designed to optimize medication use in nursing homes (NHs), and to describe its implementation outcomes in a pilot study. METHODS This was a non-randomized trial (pilot study) including NH staff and residents from five facilities. Long-stay residents at high-risk for injurious falls were identified using a validated risk calculator and staff referral. A remote team reviewed the electronic health record (EHR) and provided recommendations as Injury Prevention Plans (IPP). A research nurse served as a care coordinator focused on resident engagement and shared decision-making. Outcomes included implementation measures, as identified in the EHR, and surveys and interviews with staff. RESULTS Across five facilities, 274 residents were screened for eligibility, and 46 residents (16.8%) were enrolled. Most residents were female (73.9%) and had dementia (63.0%). An IPP was completed for 45 residents (97.8%). The nurse made a total of 93 deprescribing recommendations in 36 residents (80% of residents had one or more deprescribing recommendation; mean 2.2 recommendations/resident). Twenty of 45 residents (44.4%) had a recommendation for osteoporosis treatment. Among residents with recommendations, 21/36 (58.3%) had one or more deprescribing orders written and 6/20 (30.0%) had an osteoporosis medication prescribed. At 4 months, most medication changes persisted. Adverse side effects were rare. Staff members identified several areas for program refinement, including aligning recommendations with provider workflow and engaging consultant psychiatrists. CONCLUSIONS A remote injury prevention service is safe and feasible to enhance deprescribing and osteoporosis treatment in long-stay NH residents at risk for injury. Additional investigation is needed to determine if this model could reduce injurious falls when deployed across NH chains.
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Affiliation(s)
- Sarah D. Berry
- Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Hebrew SeniorLife, Boston, MA
- Beth Israel Deaconess Medical Center, Department of Medicine & Harvard Medical School, Boston, MA
| | - Emily J. Hecker
- Duke University School of Medicine, Department of Medicine, Division of Geriatric Medicine, Durham, NC
| | - Eleanor S. McConnell
- Durham VA Geriatric Research Education and Clinical Center, Durham, NC
- Duke University School of Nursing, Durham, NC
| | - Tingzhong-Michelle Xue
- Durham VA Geriatric Research Education and Clinical Center, Durham, NC
- Duke University School of Nursing, Durham, NC
| | - Timothy Tsai
- Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Hebrew SeniorLife, Boston, MA
| | - Andrew R. Zullo
- Brown University School of Public Health, Providence, RI
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Cathleen Colón-Emeric
- Duke University School of Medicine, Department of Medicine, Division of Geriatric Medicine, Durham, NC
- Durham VA Geriatric Research Education and Clinical Center, Durham, NC
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11
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Chan M, Plakogiannis R, Stefanidis A, Chen M, Saraon T. Pharmacist-Led Deprescribing for Patients With Polypharmacy and Chronic Disease States: A Retrospective Cohort Study. J Pharm Pract 2023; 36:1192-1200. [PMID: 35522029 DOI: 10.1177/08971900221097246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Current literature and practice have demonstrated that pharmacists have an integral role in deprescribing. However, research regarding their impact on patients with chronic diseases is limited. Objective: To assess the impact of a pharmacist-led intervention on deprescribing inappropriate medication for patients with chronic diseases within a four-month study period compared to patients receiving usual care. Methods: This study was conducted at NYU Langone Health. Patients of the intervention group were referred by a provider and met the criteria of polypharmacy, required chronic disease states management, were nonadherent to medications, had poor health literacy, or required titration for heart failure (HF) guideline directed medical therapy. Results: A total of 142 patients were reviewed over a two-year period. At the end of the study period, the median number of medications for the two respective groups was similar (11 [4 - 30] vs 11 [2 - 23]). The pharmacist-led intervention had on average one medication deprescribed (m = -1.00, sd = 2.57), whereas the control group had on average .44 additional medications (m = 0.44, sd = 3.32) prescribed. Furthermore, the intervention group presented statistically significant differences (P = 0.046) regarding their diastolic blood pressure after the pharmacists' intervention (m = 72.69, sd = 11.64). Most importantly, patients with HF presented statistically significant improvement in their ejection fractions after the intervention (m = 41.46%, sd = 19.28%). Conclusion: The pharmacist-led intervention resulted in significant discontinuation of medications for patients in the intervention group compared to those in the usual care group within four-months.
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Affiliation(s)
- Mabel Chan
- Ambulatory Care Clinical Pharmacist, NYC Health+Hospitals, Brooklyn, NY, USA
- Arnold and Marie Schwartz College of Pharmacy & Health Sciences Long Island University, Brooklyn, NY, USA
| | - Roda Plakogiannis
- Arnold and Marie Schwartz College of Pharmacy & Health Sciences Long Island University, Brooklyn, NY, USA
- PGY-2 Ambulatory Care Residency Program Director, NYU Langone Health, New York, NY, USA
| | - Abraham Stefanidis
- Department of Management, The Peter J. Tobin College of Business, St. John's University, New York, NY, USA
| | - Mandy Chen
- Arnold and Marie Schwartz College of Pharmacy & Health Sciences Long Island University, Brooklyn, NY, USA
- Shields Health Solutions, Stoughton, Massachusetts, UK
| | - Tajinderpal Saraon
- Physician, Department of Medicine, NYU Grossman School of Medicine, NY, USA
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Pilla SJ, Jalalzai R, Tang O, Schoenborn NL, Boyd CM, Golden SH, Mathioudakis NN, Maruthur NM. A National Physician Survey of Deintensifying Diabetes Medications for Older Adults With Type 2 Diabetes. Diabetes Care 2023; 46:1164-1168. [PMID: 36800554 PMCID: PMC10234750 DOI: 10.2337/dc22-2146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/25/2023] [Indexed: 02/19/2023]
Abstract
OBJECTIVE To determine physicians' approach to deintensifying (reducing/stopping) or switching hypoglycemia-causing medications for older adults with type 2 diabetes. RESEARCH DESIGN AND METHODS In this national survey, U.S. physicians in general medicine, geriatrics, or endocrinology reported changes they would make to hypoglycemia-causing medications for older adults in three scenarios: good health, HbA1c of 6.3%; complex health, HbA1c of 7.3%; and poor health, HbA1c of 7.7%. RESULTS There were 445 eligible respondents (response rate 37.5%). In patient scenarios, 48%, 4%, and 20% of physicians deintensified hypoglycemia-causing medications for patients with good, complex, and poor health, respectively. Overall, 17% of physicians switched medications without significant differences by patient health. One-half of physicians selected HbA1c targets below guideline recommendations for older adults with complex or poor health. CONCLUSIONS Most U.S. physicians would not deintensify or switch hypoglycemia-causing medications within guideline-recommended HbA1c targets. Physician preference for lower HbA1c targets than guidelines needs to be addressed to optimize deintensification decisions.
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Affiliation(s)
- Scott J. Pilla
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Rabia Jalalzai
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Olive Tang
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Nancy L. Schoenborn
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Cynthia M. Boyd
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sherita H. Golden
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nestoras N. Mathioudakis
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nisa M. Maruthur
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
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13
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Pilla SJ, Meza KA, Schoenborn NL, Boyd CM, Maruthur NM, Chander G. A Qualitative Study of Perspectives of Older Adults on Deintensifying Diabetes Medications. J Gen Intern Med 2023; 38:1008-1015. [PMID: 36175758 PMCID: PMC10039184 DOI: 10.1007/s11606-022-07828-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/16/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND While many older adults with type 2 diabetes have tight glycemic control beyond guideline-recommended targets, deintensifying (stopping or dose-reducing) diabetes medications rarely occurs. OBJECTIVE To explore the perspectives of older adults with type 2 diabetes around deintensifying diabetes medications. DESIGN This qualitative study used individual semi-structured interviews, which included three clinical scenarios where deintensification may be indicated. PARTICIPANTS Twenty-four adults aged ≥65 years with medication-treated type 2 diabetes and hemoglobin A1c <7.5% were included (to thematic saturation) using a maximal variation sampling strategy for diabetes treatment and physician specialty. APPROACH Interviews were independently coded by two investigators and analyzed using a grounded theory approach. We identified major themes and subthemes and coded responses to the clinical scenarios as positive (in favor of deintensification), negative, or ambiguous. KEY RESULTS Participants' mean age was 74 years, half were women, and 58% used a sulfonylurea or insulin. The first of four major themes was fear of losing control of diabetes, which participants weighed against the benefits of taking less medication (Theme 2). Few participants viewed glycemic control below target as a reason for deintensification and a majority would restart the medication if their home glucose increased. Some participants were anchored to their current diabetes treatment (Theme 3) driven by unrealistic views of medication benefits. A trusting patient-provider relationship (Theme 4) was a positive influence. In clinical scenarios, 8%, 4%, and 75% of participants viewed deintensification positively in the setting of poor health, limited life expectancy, and high hypoglycemia risk, respectively. CONCLUSIONS Optimizing deintensification requires patient education that describes both individualized glycemic targets and how they will change over the lifespan. Deintensification is an opportunity for shared decision-making, but providers must understand patients' beliefs about their medications and address misconceptions. Hypoglycemia prevention may be a helpful framing for discussing deintensification.
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Affiliation(s)
- Scott J Pilla
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Kayla A Meza
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nancy L Schoenborn
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cynthia M Boyd
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nisa M Maruthur
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Geetanjali Chander
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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14
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Oktora MP, Yuniar CT, Amalia L, Abdulah R, Hak E, Denig P. Attitudes towards deprescribing and patient-related factors associated with willingness to stop medication among older patients with type 2 diabetes (T2D) in Indonesia: a cross-sectional survey study. BMC Geriatr 2023; 23:21. [PMID: 36635653 PMCID: PMC9835373 DOI: 10.1186/s12877-022-03718-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/27/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Deprescribing of preventive medication is recommended in older patients with polypharmacy, including people with type 2 diabetes (T2D). It seems that many patients in low-middle-income countries are not willing to have their medicines deprescribed. This study aims to assess attitudes of Indonesian patients with T2D towards deprescribing in general and regarding specific cardiometabolic medicines, and factors influencing their willingness to stop medicines. METHODS Primary care patients with T2D of ≥60 years in Indonesia completed the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. Attitudes in general and for cardiometabolic medicines were reported descriptively. Proportions of patients willing to stop one or more medicines when recommended by different healthcare professionals were compared with Chi-square test. Multiple regression analysis was used to analyse the influence between patient-related factors and the willingness to stop medicines. RESULTS The survey was completed by 196 participants (median age 69 years, 73% female). The percentages willing to stop medicines were 69, 67, and 41%, when the general practitioner (GP), the specialist, or the pharmacist initiates the process (p-value < 0.001). Higher perceived burden of medicines (p-value = 0.03) and less concerns about stopping (p-value < 0.001) were associated with a higher willingness to stop medicines if proposed by the GP. Patients using multiple glucose-regulating medicines were less willing to stop (p-value = 0.02). Using complementary or alternative medicines was not associated with the willingness to stop. If proposed by their pharmacist, patients without substantial education were more willing to stop than educated patients. CONCLUSIONS Only two-thirds of older people with T2D in Indonesia were willing to stop one or more of their medicines if the GP or specialist recommended this, and even less when the pharmacist proposed this. Attention should be given to concerns about stopping specific medicines, especially among patients using multiple glucose-lowering medicines, who may be more eligible but were less willing to accept deprescribing.
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Affiliation(s)
- Monika Pury Oktora
- grid.4830.f0000 0004 0407 1981University Medical Center Groningen (UMCG), Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, The Netherlands
| | - Cindra Tri Yuniar
- grid.434933.a0000 0004 1808 0563School of Pharmacy, Department of Pharmacology and Clinical Pharmacy, Institut Teknologi Bandung (ITB), Bandung, Indonesia
| | - Lia Amalia
- grid.434933.a0000 0004 1808 0563School of Pharmacy, Department of Pharmacology and Clinical Pharmacy, Institut Teknologi Bandung (ITB), Bandung, Indonesia
| | - Rizky Abdulah
- grid.11553.330000 0004 1796 1481Faculty of Pharmacy, Department of Pharmacology and Clinical Pharmacy, Universitas Padjadjaran (UNPAD), Bandung, Indonesia
| | - Eelko Hak
- grid.4830.f0000 0004 0407 1981Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, -Epidemiology and –Economics, University of Groningen, Groningen, The Netherlands
| | - Petra Denig
- grid.4830.f0000 0004 0407 1981University Medical Center Groningen (UMCG), Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, The Netherlands
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15
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Ambrož M, Geelink M, Smits KPJ, de Vries ST, Denig P. Sex disparities in medication prescribing amongst patients with type 2 diabetes mellitus managed in primary care. Diabet Med 2023; 40:e14987. [PMID: 36278892 PMCID: PMC10098565 DOI: 10.1111/dme.14987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/25/2022] [Accepted: 10/19/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Sex differences in clinical outcomes have been observed for patients with type 2 diabetes mellitus (T2DM). These could be related to sex disparities in treatment. OBJECTIVES To determine whether there are sex disparities in medication prescribing amongst patients with T2DM. METHODS A cohort study was conducted using the Groningen Initiative to ANalyze Type 2 diabetes Treatment (GIANTT) database, which includes data from primary care patients with T2DM from the north of the Netherlands. Data on demographics, physical examinations, laboratory measurements and prescribing were extracted. A set of validated prescribing quality indicators assessing the prevalence, start, intensification and safety of glucose-, lipid-, blood pressure- and albuminuria-lowering medication was applied for the calendar year 2019. Univariate logistic regression analyses were conducted. RESULTS We included 10,456 patients (47% females). Females were less often treated with metformin (81.7% vs. 86.5%; OR 0.70, 95% CI 0.61-0.80), and were less often prescribed a renin-angiotensin-aldosterone inhibitor (RAAS-i) when treated with multiple blood pressure-lowering medicines (81.9% vs. 89.3%; OR 0.55, 95% CI 0.46-0.64) or when having albuminuria (74.7% vs. 82.1%; OR 0.64, 95% CI 0.49-0.85) than males. Statin treatment was less frequently started (19.7% vs. 24.7%; OR 0.75, 95% CI 0.58-0.96) and prescribed (58.7% vs. 63.9%; OR 0.80, 95% CI 0.73-0.89) in females. There were no differences in starting and intensifying glucose-, blood pressure- and albuminuria-lowering medication. CONCLUSIONS Sex disparities in medication prescribing amongst T2DM patients were seen, including less starting with statins and potential undertreatment with RAAS-i in females. Such disparities may partly explain higher excess risks for cardiovascular and renal complications associated with diabetes observed in females.
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Affiliation(s)
- Martina Ambrož
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen (UMCG), Groningen, The Netherlands
| | - Marit Geelink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen (UMCG), Groningen, The Netherlands
| | - Kirsten P J Smits
- Department of Dentistry - Quality and Safety of Oral Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Sieta T de Vries
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen (UMCG), Groningen, The Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen (UMCG), Groningen, The Netherlands
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16
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Russell AM, Opsasnick L, Yoon E, Bailey SC, O'Brien M, Wolf MS. Association between medication regimen complexity and glycemic control among patients with type 2 diabetes. J Am Pharm Assoc (2003) 2022; 63:769-777. [PMID: 36682933 DOI: 10.1016/j.japh.2022.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 12/02/2022] [Accepted: 12/28/2022] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Type 2 diabetes mellitus (T2DM) and comorbid conditions require patients to take complex medication regimens. Greater regimen complexity has been associated with poorer T2DM management; however, the relationship between overall regimen complexity and glycemic control is unclear. OBJECTIVES Our objectives were: (1) to examine associations between regimen complexity (with the Medication Regimen Complexity Index [MRCI]) and glycemic control (A1C), and (2) to compare overall MRCI with other measures of regimen complexity (overall and diabetes-specific medication count) and diabetes-specific MRCI. METHODS This was a secondary data analysis of cross-sectional data from a parent trial. Participants were patients with T2DM taking at least 3 chronic medications followed in safety net clinics in the Chicago area. The MRCI measures complexity based on dosing frequency, route of administration, and special instructions for prescribed medications. MRCI scores were created for overall regimens and diabetes-specific medications. Sociodemographics and outpatient visit utilization were included in models as covariates. Linear regression was used to examine the associations between variables of interest and hemoglobin A1C. RESULTS Participants (N = 432) had a mean age of 56.9 years, most were female (66.0%), and Hispanic or Latino (73.3%). Regimen complexity was high based on overall medications (mean = 6.6 medications, SD: 3.09) and MRCI (mean = 21.4, SD: 11.3). Higher diabetes-specific MRCI was associated with higher A1C in bivariate and multivariable models. In multivariable models, overall MRCI greater than 14, fewer outpatient health care visits, male gender, and absence of health insurance were independently associated with higher A1C. The variance in A1C explained by MRCI was higher compared to medication count for overall and diabetes-specific regimen complexity. CONCLUSIONS More complex regimens are associated with worse A1C and measuring complexity with MRCI may have advantages. Deprescribing, increasing insurance coverage, and promoting engagement in health care may improve A1C among underserved populations with complex regimens.
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17
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Lederle LI, Steinman MA, Jing B, Nguyen B, Lee SJ. Glycemic treatment deintensification practices in nursing home residents with type 2 diabetes. J Am Geriatr Soc 2022; 70:2019-2028. [PMID: 35318647 PMCID: PMC9283249 DOI: 10.1111/jgs.17735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/02/2022] [Accepted: 02/12/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Older nursing home (NH) residents with glycemic overtreatment are at significant risk of hypoglycemia and other harms and may benefit from deintensification. However, little is known about deintensification practices in this setting. METHODS We conducted a cohort study from January 1, 2013 to December 31, 2019 among Veterans Affairs (VA) NH residents. Participants were VA NH residents age ≥65 with type 2 diabetes with a NH length of stay (LOS) ≥ 30 days and an HbA1c result during their NH stay. We defined overtreatment as HbA1c <6.5 with any insulin use, and potential overtreatment as HbA1c <7.5 with any insulin use or HbA1c <6.5 on any glucose-lowering medication (GLM) other than metformin alone. Our primary outcome was continued glycemic overtreatment without deintensification 14 days after HbA1c. RESULTS Of the 7422 included residents, 17% of residents met criteria for overtreatment and an additional 23% met criteria for potential overtreatment. Among residents overtreated and potentially overtreated at baseline, 27% and 19%, respectively had medication regimens deintensified (73% and 81%, respectively, continued to be overtreated). Long-acting insulin use and hyperglycemia ≥300 mg/dL before index HbA1c were associated with increased odds of continued overtreatment (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.14-1.65 and OR 1.35, 95% CI 1.10-1.66, respectively). Severe functional impairment (MDS-ADL score ≥ 19) was associated with decreased odds of continued overtreatment (OR 0.72, 95% CI 0.56-0.95). Hypoglycemia was not associated with decreased odds of overtreatment. CONCLUSIONS Overtreatment of diabetes in NH residents is common and a minority of residents have their medication regimens appropriately deintensified. Deprescribing initiatives targeting residents at high risk of harms and with low likelihood of benefit such as those with history of hypoglycemia, or high levels of cognitive or functional impairment are most likely to identify NH residents most likely to benefit from deintensification.
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Affiliation(s)
- Lauren I. Lederle
- Geriatrics and Extended Care ServiceSan Francisco Virginia Medical CenterSan FranciscoCaliforniaUSA
- Veterans Affairs Quality Scholars FellowshipSan Francisco Virginia Medical CenterSan FranciscoCaliforniaUSA
- Division of GeriatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Michael A. Steinman
- Geriatrics and Extended Care ServiceSan Francisco Virginia Medical CenterSan FranciscoCaliforniaUSA
- Division of GeriatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Bocheng Jing
- Division of GeriatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Brian Nguyen
- Division of GeriatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Sei J. Lee
- Geriatrics and Extended Care ServiceSan Francisco Virginia Medical CenterSan FranciscoCaliforniaUSA
- Veterans Affairs Quality Scholars FellowshipSan Francisco Virginia Medical CenterSan FranciscoCaliforniaUSA
- Division of GeriatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
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18
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[Deprescription in old people: It's time to take action]. Aten Primaria 2022; 54:102367. [PMID: 35653980 PMCID: PMC9160471 DOI: 10.1016/j.aprim.2022.102367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 12/02/2022] Open
Abstract
El uso de fármacos conlleva innegables beneficios en las personas mayores, pero no está exento de efectos indeseables. La deprescripción es el proceso de revisión sistemática de la medicación con el objetivo de lograr la mejor relación riesgo-beneficio en base a la mejor evidencia disponible. Este proceso es especialmente importante en mayores polimedicados, sobretratados, frágiles, con enfermedades terminales y en el final de la vida. La deprescripción debe hacerse de forma escalonada, estableciendo un seguimiento estrecho por si aparecen problemas tras la retirada. En la toma de decisiones es muy importante contar con la opinión del paciente y de los cuidadores, valorando los objetivos del tratamiento según la situación clínica, funcional y social del enfermo. Existen múltiples herramientas para facilitar a los clínicos la tarea de seleccionar qué fármacos deprescribir (criterios Beers, STOPP-START…). Los grupos farmacológicos más susceptibles de intervención son: antihipertensivos, antidiabéticos, estatinas, benzodiacepinas, antidepresivos, anticolinérgicos, anticolinesterásicos y neurolépticos.
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19
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Ambrož M, de Vries ST, Hoogenberg K, Denig P. Less Timely Initiation of Glucose-Lowering Medication Among Younger and Male Patients With Diabetes and Similar Initiation of Blood Pressure-Lowering Medication Across Age and Sex: Trends Between 2015 and 2020. Front Pharmacol 2022; 13:883103. [PMID: 35645811 PMCID: PMC9133603 DOI: 10.3389/fphar.2022.883103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/13/2022] [Indexed: 11/15/2022] Open
Abstract
Aims: We aimed to assess trends in glycosylated hemoglobin A1c (HbA1c) and systolic blood pressure (SBP) thresholds at initiation of glucose- and blood pressure-lowering medication among patients with type 2 diabetes and assess the influence of age and sex on these trends. Materials and Methods: We used the Groningen Initiative to ANalyze Type 2 diabetes Treatment (GIANTT) primary care database. Patients initiating a first non-insulin glucose-lowering or any blood pressure-lowering medication between 2015 and 2020 with an HbA1c or SBP measurement in the 120 days before initiation were included. We used multilevel regression analyses adjusted for potential confounders to assess the influence of calendar year, age or sex, and the interaction between calendar year and age or sex on trends in HbA1c and SBP thresholds at initiation of medication. Results: We included 2,671 and 2,128 patients in the analyses of HbA1c and SBP thresholds, respectively. The overall mean HbA1c threshold at initiation of glucose-lowering medication significantly increased from 7.4% in 2015 to 8.0% in 2020 (p < 0.001), and particularly in the younger age groups. Compared to patients ≥80 years, patients aged 60–69 years initiated medication at lower levels mainly in the early years. Patients <60 years and between 70–79 years initiated medication at similar levels as patients ≥80 years. Females initiated medication at lower levels than males throughout the study period (p < 0.001). The mean SBP threshold at initiation of blood pressure-lowering medication varied from 145 to 149 mmHg without a clear trend (p = 0.676). There were no differences in SBP thresholds between patients of different ages or sex. Conclusion: The rising trend in the HbA1c threshold for initiating glucose-lowering medication in the lower age groups was unexpected and requires further investigation. Males appear to receive less timely initiation of glucose-lowering medication than females. The lack of higher thresholds for the oldest age group or lower thresholds for the youngest age group in recent years is not in line with the age-related recommendations for personalized diabetes care and calls for health systems interventions.
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Affiliation(s)
- Martina Ambrož
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Sieta T. de Vries
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Klaas Hoogenberg
- Department of Internal Medicine, Martini Hospital, Groningen, Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- *Correspondence: Petra Denig,
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Jude EB, Malecki MT, Gomez Huelgas R, Prazny M, Snoek F, Tankova T, Giugliano D, Khunti K. Expert Panel Guidance and Narrative Review of Treatment Simplification of Complex Insulin Regimens to Improve Outcomes in Type 2 Diabetes. Diabetes Ther 2022; 13:619-634. [PMID: 35274219 PMCID: PMC8913205 DOI: 10.1007/s13300-022-01222-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 02/02/2022] [Indexed: 11/03/2022] Open
Abstract
Given the progressive nature of type 2 diabetes (T2D), most individuals with the disease will ultimately undergo treatment intensification. This usually involves the stepwise addition of a new glucose-lowering agent or switching to a more complex insulin regimen. However, complex treatment regimens can result in an increased risk of hypoglycaemia and high treatment burden, which may impact negatively on both therapeutic adherence and overall quality of life. Individuals with good glycaemic control may also be overtreated with unnecessarily complex regimens. Treatment simplification aims to reduce individual treatment burden, without compromising therapeutic effectiveness or safety. Despite data showing that simplifying therapy can achieve good glycaemic control without negatively impacting on treatment efficacy or safety, it is not always implemented in clinical practice. Current clinical guidelines focus on treatment intensification, rather than simplification. Where simplification is recommended, clear guidance is lacking and mostly focused on treatment of the elderly. An expert, multidisciplinary panel evaluated the current treatment landscape with respect to guidance, published evidence, recommendations and approaches regarding simplification of complex insulin regimens. This article outlines the benefits of treatment simplification and provides practical recommendations on simplifying complex insulin treatment strategies in people with T2D using illustrative cases.
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Affiliation(s)
- Edward B Jude
- Tameside and Glossop Integrated Care NHS Foundation Trust, Ashton-under-Lyne, UK
- University of Manchester, Manchester, UK
| | - Maciej T Malecki
- Department of Metabolic Diseases, Jagiellonian University Medical College, Kraków, Poland
| | - Ricardo Gomez Huelgas
- Internal Medicine Department, Regional University Hospital of Málaga, Málaga, Spain
- Instituto de Investigación Biomédica de Málaga (IBIMA), University of Málaga, Málaga, Spain
- CIBER Fisiopatología de la Obesidad y la Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
| | - Martin Prazny
- 3rd Department of Internal Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Frank Snoek
- Department of Medical Psychology, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | | | - Dario Giugliano
- Division of Endocrinology and Metabolic Diseases, University Hospital, Università della Campania Luigi Vanvitelli, Naples, Italy
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK.
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Barriers and Enablers of Healthcare Providers to Deprescribe Cardiometabolic Medication in Older Patients: A Focus Group Study. Drugs Aging 2022; 39:209-221. [PMID: 35187614 PMCID: PMC8934783 DOI: 10.1007/s40266-021-00918-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2021] [Indexed: 12/13/2022]
Abstract
Introduction Benefits and risks of preventive medication change over time for ageing patients and deprescribing of medication may be needed. Deprescribing of cardiovascular and antidiabetic drugs can be challenging and is not widely implemented in daily practice. Objective The aim of this study was to identify barriers and enablers of deprescribing cardiometabolic medication as seen by healthcare providers (HCPs) of different disciplines, and to explore their views on their specific roles in the process of deprescribing. Methods Three focus groups with five general practitioners, eight pharmacists, three nurse practitioners, two geriatricians, and two elder care physicians were conducted in three cities in The Netherlands. Interviews were recorded and transcribed verbatim. Directed content analysis was performed on the basis of the Theoretical Domains Framework. Two researchers independently coded the data. Results Most HCPs agreed that deprescribing of cardiometabolic medication is relevant but that barriers include lack of evidence and expertise, negative beliefs and fears, poor communication and collaboration between HCPs, and lack of resources. Having a guideline was considered an enabler for the process of deprescribing of cardiometabolic medication. Some HCPs feared the consequences of discontinuing cardiovascular or antidiabetic medication, while others were not motivated to deprescribe when the patients experienced no problems with their medication. HCPs of all disciplines stated that adequate patient communication and involving the patients and relatives in the decision making enables deprescribing. Barriers to deprescribing included the use of medication initiated by specialists, the poor exchange of information, and the amount of time it takes to deprescribe cardiometabolic medication. The HCPs were uncertain about each other’s roles and responsibilities. A multidisciplinary approach including the pharmacist and nurse practitioner was seen as the best way to support the process of deprescribing and address barriers related to resources. Conclusion HCPs recognized the importance of deprescribing cardiometabolic medication as a medical decision that can only be made in close cooperation with the patient. To successfully accomplish the process of deprescribing they strongly recommended a multidisciplinary approach.
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Benefits and Harms of Deprescribing Antihyperglycemics for Adults with Type 2 Diabetes: A Systematic Review. Can J Diabetes 2022; 46:473-479. [DOI: 10.1016/j.jcjd.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 12/09/2021] [Accepted: 01/27/2022] [Indexed: 11/19/2022]
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Affiliation(s)
- Carole E Aubert
- Department of General Internal Medicine, Inselspital, Bern University Hospital, and Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Iliana C Lega
- Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Olivier Bourron
- Sorbonne University, Diabetology Department, Pitié-Salpêtrière-Charles Foix Hospital, AP-HP, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Alice J Train
- Office of Patient Experience (OPE), Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jeffrey T Kullgren
- Ann Arbor VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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